Provider Demographics
NPI:1801830757
Name:MCKENZIE, KEITH CRESWELL (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:CRESWELL
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:15501 METROPOLITAN PKWY
Mailing Address - Street 2:STE 110
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1684
Mailing Address - Country:US
Mailing Address - Phone:586-286-9720
Mailing Address - Fax:586-286-3134
Practice Address - Street 1:15501 METROPOLITAN PKWY
Practice Address - Street 2:STE 110
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-1684
Practice Address - Country:US
Practice Address - Phone:586-286-9720
Practice Address - Fax:586-286-3134
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301067883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0805013811OtherBCBSM OF MICHIGAN
MI352206784OtherTAX ID
MI0P03910001Medicare PIN
MI352206784OtherTAX ID